Gastroenterology Approach to GI Track Blood Loss

8/19/2019 Gastroenterology Approach to GI Track Blood Loss

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Gastroenterology

Approach toGI Tract Blood Loss

Heather Kohout, BS,BMS,MPA,PDHSc Candidate

October 25, 2015


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Requests for additional gastroenterologhepatology resources than were provide

well as any requests for use of theintellectual material presented in th

presentation can be sent to the followcontact information:

Heather Kohout, BS,BMS,MPA,PA-C,DHSc Candid45 Nicola Road, St.Albert, AB, T8N 7M7

[email protected]/heatherkohout

mailto:[email protected]://www.linkedin.com/heatherkohouthttp://www.linkedin.com/heatherkohoutmailto:[email protected]


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Disclosures

I have no financial, commercial, or educational relationsinterests to disclose.

I am a Canadian Association of Physician Assistants (CAmember participating on the CAPA Conference Planning

Committee. I am also a member of the Canadian PhysicAssistant Education Association (CPAEA), the Americanof Physician Assistants (AAPA), & the Physician AssistaEducation Association (PAEA).

Figure 1. Logo. Canadian Association of Physician Assistants. Retrieved from https://capa-acam.ca/; Figure 2. Logo. American Aca

Retrieved from https://aapa.org/; Figure 3. Logo. Physician Assistant Education Association. Retrieved from http://www.paeaonlinPhysician Assistant Education Association. Retrieved from https://capa-acam.ca/


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Disclosures

I have provided at the end of this lecture a list of resourcegastroenterology & hepatology specialized PA practice. Tinclude published references & professional organizationavailable memberships, conferences, & informative mate

I recommend these resources due to my professional expdo not have any financial, commercial, or educational cointerest in offering recommendation of these resources.

Figure 5. Logo. From Canadian Association of Gastroenterology. (n.d.). Retrieved from https://www.cag-acg.org/; Figure 6. Logo. Fr

(n.d.). Retrieved from http://www.liver.ca/; Figure 7. Logo. From Canadian Association for the Study of the Liver. (n.d.). Retrieved fr

Figure 8. Logo. From American College of Gastroenterology. (n.d.). Retrieved from http://gi.org/; Figure 9. Logo. From American Ga

(n.d.). Retrieved from http://www.gastro.org/; Figure 10. Logo. From American Association for the Study of Liver Diseases. Retrieve


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DisclosuresPractice experience within family practice & internal m

prior to specializing in gastroenterology & hepatology

Practice experience in Wisconsin, Illinois, Kentucky, &Colorado. I live in Alberta, but I do not have practiceexperience within Canada.

Practice experience in rural, suburban, & metropolitanwell as in a solo-physician private family practice, a sm

private family practice, a large private health organizalarge private specialty practices, & a large non-for-proorganization.


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Objectives

After attending this lecture the attendee should be able

• Distinguish between upper, lower, & occult GI trasources of blood loss with estimation of etiology

prevalence.

• Identify evaluative methods for diagnosis & treatm

upper, lower, & occult GI tract blood loss etiologi• Interpret clinical scenarios demonstrating upper, lo

occult GI tract blood loss presentation.

• Locate & share professional resources for GI & livdisease.


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Types of GI Tract Blood Lo

•Upper GI Tract Blood Loss

•Lower GI Tract Blood Loss

•Occult GI Tract Blood Loss


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Upper GI Tract Blood LosEsophagus Etiologies:

• Mallory Weiss Tear • Foreign Body• Esophagitis

•Esophageal Varices• Cameron’s Ulcers• Esophageal Cancer •Aortoenteric Fistula

•Boerhaave’s Esophagus Figure 11. Esophagus. From Organ Esophagus definition, information, a

http://www.organsofthebod


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Upper GI Tract Blood Los•Mallory Weiss Tear

• Non-penetrating mucosal tear, common at GE junction.

• Presents with recent hx emesis &/or retching, followed byhematemesis/coffee ground emesis.

• UGI endoscopy, i.e. esophagogastroduodenoscopy (EGD), c& rules out alternative ddx.

• Usually self-limiting, monitor Hgb, hydrate. (Friedman, Mc

•Foreign Body• Commonly large unchewed food boluses (dry chicken, steak

• Presents when eating with food bolus that won’t pass, possismall amount hematemesis.

• EGD to remove food bolus, necessary to prevent esophageafollowed by supportive care usually at home

(Friedman, Mc


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Upper GI Tract Blood Los• Esophagitis

• Mucosal injury from either ingestion of caustic substances (

pills (Potassium), infectious etiologies (Candida, HSV/CMVexposure, or due to esophageal dysmotility/stasis of food bo(achalasia, Zenker’s diverticulum).

• Presents after caustic ingestion, pill or food bolus unable tothoracic radiation exposure, common in immunocompromis

with hematemesis/coffee ground emesis, &/or melena.• EGD confirms dx, removes pills or food, & obtains bx for i

endoscopic findings indicative. Contrast studies dx, but can

• Caustic, pill, & food bolus injuries usually self-limiting. DyZenker’s need f/u depending on severity. Candida & viral in

according to guidelines w/antifungals & antivirals.(Friedman, McQ


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Upper GI Tract Blood Los•Esophageal Cancer

• Adenocarcinoma & squamous cell carcinoma (SCC), most c

esophageal cancers worldwide, SCC is 5th

most common GIglobally, 5-yr survival 2-26% depends on presenting dx stag

• Strongest risk factor for adenocarcinoma is Barrett’s esophaadvancing age, male sex, chronic GERD, Caucasian ethnicit

• SCC risk factors include environmental exposure to tobacconitrosamines, & radiation (i.e. breast ca or Hodgkin’s tx), co

hot or caustic substances, chronic esophageal food stasis (acnutritional deficiencies (i.e. Vit C), & geographic area.

• Presents with solid-food dysphagia (early), mixed dysphagiaodynophagia, unintentional weight loss, & possibly hematemground emesis, &/or melena.

• EGD confirms & obtains bx for dx. Contrast studies dx, but

Oncology & surgery tx depends on staging. (Hause


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Upper GI Tract Blood Los• Cameron’s Ulcers

• Esophageal shallow mucosal ulcerations in a hiatal hernia (H

with hematemesis/coffee ground emesis, &/or melena. EGDreflux tx & HH recommendations. (Friedman, McQua

• Boerhaave’s Esophagus• Traumatic (distal location) or iatrogenic instrumentation (rar

location) caused esophageal rupture. Presents hx emesis & rew/hematemesis/coffee ground emesis [or after recent EGD]chest & abdominal px. Dx STAT CXR. Contrast esophagramconfirms & thoracic surgical correction. No EGD! (Friedman, McQu

• Aortoenteric Fistula• Aorta & GI tract direct tract communication, very rare, prese

hematemesis. Caused by aortic aneurysm, syphilitic or Tb-asinfectious aorititis, prosthetic aortic graft eroding infection, pan ulcer, tumor, trauma, radiation exposure, or foreign body.

correction. (Friedman, McQu


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UGI Tract Blood Loss: Case •What is the DDx?

Foreign Body (pill or food),

MW (maybe), Esophagitis (pill,

infectious, reflux, motility),

Esophageal Ca (Adeno & SCC

risk factors).

•What should you do?Keep pt NPO, consult GI for

EGD, DDx concerning for foreign

body warranting urgent EGD.

Figure 12. Esophagitis. From Harrison’s Principles of Internal Medicine, 17th ed. (2008). Endoscopy images A, B, C, and D. New York, N


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Upper GI Tract Blood LosEsophagus Etiologies:

•Mallory Weiss Tear •Foreign Body• Esophagitis

•Esophageal Varices

•Cameron’s Ulcers• Esophageal Cancer • Aortoenteric Fistula

•Boerhaave’s Esophagus


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Upper GI Tract Blood Los

Gastric Etiologies:

• Gastritis

• Peptic Ulcer Disease (PUD)

• Portal Hypertensive Gastropathy

• Dieulafoy’s Lesion

• Angiodysplasia

• Gastric Antral Vascular Ectasia

• Gastric CarcinomaFigure 13. Stomach. From Organsofth

stomach, stomach functions, and

http://www.organsofthebod


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Upper GI Tract Blood LoGastritis

• Mucosal injury & erosions from Rx (NSAIDs, ASA), Etoh, Greflux, dysmotility.

• Presents w/repeated Rx usage or Etoh consumption, w/hemateground emesis, &/or melena.• EGD or contrast study to dx. Usually self-limiting, conservati NSAIDs/ASA or Etoh, monitor Hgb, hydrate. (Friedman, M

Peptic Ulcer Disease (PUD)• Gastric (& duodenal) mucosal ulcers from Rx, H. pylori, hype

(GERD, bile reflux) & hypersecretory states (ZES, gastrinomischemia, stress i.e. ICU hospitalization.• Presents w/chronic Rx/Etoh usage, +/- abdominal pain, GERD

hematemesis/coffee ground emesis, &/or melena• EGD confirms dx, cauterizes vessel, & bx ulcers for H. pylori

recurrent PUD. Tx IV PPI 24-48 hrs then PO 4-8wks, tx H.guidelines ; no NSAIDs, ASA, Etoh, or steroids, monitor Hgb

(Friedman, M


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Upper GI Tract Blood LoDieulafoy’s Lesion & Angiodysplasia (AVMs)

•

Bleeding vessel not associated with mucosal injury or ulcerat• Presents with recurrent GI bleed, melena or heme+ stools, ir

anemia. EGD w/cautery tx, monitor Hgb. Tagged RBCs scan bleed not found via EGD. (Friedman, Mc

Gastric Antral Vascular Ectasia (GAVE)

• Longitudinal erythematous mucosal rows from the pylorus towith a watermelon appearance, confirmed w/EGD.

• Presents with recurrent GI bleed, melena or heme+ stools, iranemia.

• EGD visible or bx confirmation, tx w/heater probe cautery or

or antrectomy, monitor Hgb. (Friedman, Mc


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Upper GI Tract Blood LoGastric Carcinoma

• Adenocarcinoma 95%; also lymphomas, stromal & neuroend

tumors, & metastatic dz. Common presentation is late stage d

• Adenocarcinoma risk factors are diet high in nitrate compoun processed meats, fried foods, & Etoh, low in raw fruits & vetobacco usage, s/p Billroth II/I, EBV or H. pylori infx, FHx,

polyps, & pernicious anemia.

• Presents w/vague sxs: epigastric px, early satiety, bloating, dunintentional weight loss, nausea, & anorexia (late); distal anw/gastric outlet obstructive (GOO) sxs; cardia/GE junction wLAD & ascites w/distal spread; occult or acute bleeding stag

• EGD dx. EGD & contrast studies for staging. Oncology & su

depends on staging. (Hauser, P


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UGI Tract Blood Loss: Case S• What is the DDx?

Gastritis, PUD,

Gastric Carcinoma.

• What do you do?

Transfuse, stabilize

BP, start IV PPI,

consult GI for

urgent EGD with bxs.

Figure 15. Duodenal U

Gastrointestinal Site. (n.d.). D

from http://www.kolumb

Figure 14. Gastric Ulcer. From Gastrolab - the

Gastrointestinal Site. (n.d.). Prepyloric ulcers

& erosions due to NSAID’s.

Retrieved from http://www.gastrolab.net/pa-207.htm


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Upper GI Tract Blood LosGastric Etiologies:

•Gastritis

• Peptic Ulcer Disease

•Portal Hypertensive Gastropathy

•Dieulafoy’s Lesion

• Angiodysplasia

• Gastric Antral Vascular Ectasia

• Gastric Carcinoma


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Other Etiologies:

• Duodenal Varices

•Hemobilia

• Hemosuccus Pancreaticus

•Cancer (duodenal, biliary, pancreatic, abdominal)

•Crohn’s Disease (see IBD lecture)Figure 16. Small Intestine. From Org

Small intestine function, parts wi

http://www.organsofthebody.

U GI T Bl d L


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Upper GI Tract Blood LosPortal Hypertension (Portal HTN)• Dx increased portal venous pressure gradient (PVPG) from hepa

portocollateral resistance of cirrhosis. Hepatic resistance of vasofrom increased intrahepatic endothelin & decreased intrahepatic Systemic vasodilation (esophagus, gastric, duodenal, & rectal blfrom systemic increased nitrous oxide levels. Portal HTN leads t

plasma volume expansion & cardiac output, lessened autonomicsystem response, & increased systemic levels of glucagon, prost

(PGs), tumor necrosis factor alpha (TNFa), & cytokines.• Tx vasoconstrictors (nonselective beta blockers [prevention], s

[IV drip w/bleed], vasopressin [refractory resuscitation]) decrea blood flow & PVPG.

• Tx vasodilators (nitroglycerin, long-acting nitrates, prazosin)endothelin resistance w/side effects. (

U GI T t Bl d L


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Upper GI Tract Blood LoVariceal GI Bleed

• Presents with large volume hematemesis &/or coffee ground em&/or hematochezia with hypotension requiring emergent volumvia pRBCs, FFP, & IVFs (NS & ½NS). Possibly Vitamin K &/Possibly Recombinant Activated-Factor VII. Consider antibiotic(to reduce risk of spontaneous bacterial peritonitis (SBP)).

• Dx & Tx w/emergent EGD w/band ligation, +/- sclerotherapy ofPPI drip (to maximize healing of ulcerations w/vessels) & IV oc

(for vasoconstriction of varices).(Lee, Larson, & Stravitz, 2011;

• Follow AASLD guidelines for management. Pressor support (doepinephrine, norepinephrine) likely needed, reserve vasopress& norepinephrine resuscitation failure. Avoid nephrotoxicity, cocontinuous hemodialysis as necessary. Consider enteral feedingsFollow glucose, potassium, magnesium, & phosphate closely.

(Garcia-Tsao, Sanyal, Grace, Carey, AASLD, & ACG, 2007; Lee, Larson, & Stravitz, 2011;

U GI T t Bl d L


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Upper GI Tract Blood LoVariceal GI Bleed Co-Morbidities• Variceal bleed complications include death & acute/chronic liv

comorbidities, i.e. SBP, hepatic encephalopathy (HE), hepatore(HRS). Consider Transjugular Intrahepatic Portosystemic Shunfailure of variceal bleed to all above tx options according to AAguidelines.

Liver Disease Evaluation• DDx includes Etoh, NAFLD, Chronic Hepatitis C (HCV Ab, H

load & genotype), Chronic Hepatitis B (HBVcIgM, HBVcTotaHBVsAb), Hemachromatosis (Iron studies, ferritin level, HFE Autoimmune (AMA, ASMA, ANA, Anti-LKM Ab), Alpha-1-ADeficiency (Alpha-1 phenotype), Wilson’s Disease (ceruloplasserum levels, 24 hr urine copper level, & slit lamp eye exam byophthalmologist). Dx via Hx, FHx, SHx, labs, abdominal U/S &/or liver bx. HCC screening per AASLD guidelines.

(Garcia-Tsao, Sanyal, Grace, Carey, AASLD, & ACG, 2007; Lee, Larson, & Stravitz, 2011; Frie


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UGI Tract Blood Loss: Case • What is this?

Cirrhotic Esophageal

Variceal Bleed

• What do you do?

STAT GI consult, volume

expanders (pRBCs, FFP, IVFs)

pressors, antibiotic prophylaxis,

IV PPI & octreotide drips,

Vit K, & EGD w/banding.

Figure 17. Esophageal Variceal Bleed. From

Gastrointestinalatlas.com (2015). Esophageal

and gastric varices. Retrieved from

http://www.gastrointestinalatlas.com/english/varices.html

Figure 18. Eso

Gastroin

Variceal b

http://www.gas

varic

U GI T Bl d L


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Upper GI Tract Blood LoHemobilia

• Biliary system source of bleeding (gallstone(s), trauma, hep

tumor(s) or abscess, hepatic artery aneurysm), presents as bobstructive jaundice, & occult or acute GI bleed triad.

• Dx with side-viewing EGD. Tx underlined etiology, ERCP biliary tree stone. (Friedman, McQu

Hemosuccus pancreaticus• Pancreatic duct source of rare bleeding (pseudocyst(s) or tu

erosion into vessel).

• Dx & tx with endoscopic retrocholangiopancreatography (Esurgical vessel ligation, or mesenteric arteriography with co

embolization. (Friedman, McQ


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Upper GI Tract Blood LoCancer

•

Gastrointestinal malignancy of the duodenum, biliary systemduct, or invasion from adjacent abdominal structures

• May present with occult or acute GI bleeding & other sxs dinvolvement.

• Endoscopic evaluation via EGD with bx, endoscopic ultrasowith bx or fine needle aspiration, or endoscopicretrocholangiopancreatography (ERCP) with bx or stent pla

• Tx underlined etiology. (Friedman, McQua

U GI T t Bl d L


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Other Etiologies:

•Duodenal Ulcers (see PUD)

•Duodenal Varices

•Hemosuccus Pancreaticus

•Hemobilia•Cancer (duodenal, biliary,

pancreatic, abdominal)

• Crohn’s Disease (see IBD lecture)


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Lower GI Tract Blood Lo

Small Intestinal Etiologies:• Crohn’s Disease (see IBD lecture)

•Arteriovenous Malformations (AVMs

L GI T Bl d L


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Lower GI Tract Blood LoSmall Bowel Vascular Ectasias (AVMs)

•

Bleeding vessel not associated with mucosal injury or ulcer• Presents with recurrent GI bleed, melena or heme+ stools,

deficient anemia. EGD or Small Bowel Push Enteroscopy oColonoscopy into distal small bowel, w/cautery tx, monitorTagged RBCs scan if vigorous bleed not found endoscopica

(Friedman, McQuaid

Distal Small Bowel Crohn’s Disease• (see IBD lecture)

L GI T Bl d L


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Lower GI Tract Blood LoColon Etiologies:

•Infectious Colitis

•Mesenteric Ischemic Colitis•Diverticular Bleed

• Postpolypectomy Bleed• Radiation Colitis

•Meckel’s Diverticulum• Colon Cancer

• Arteriovenous Malformations•Crohn’s Disease• Ulcerative Colitis

Figure 21. Colon. From Organso

large intestine information an

http://www.organsofthebody



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Lower GI Tract Blood LoInfectious Colitis

• Mucosal injury & ulcerations due to infection (Campylobacter jSalmonella, Shigella, invasive E.coli, or C. difficile). Presents w

diarrhea, hematochezia, abdominal pain, & fever.• Dx stool studies/cultures, colonoscopy w/bx. Tx underlined etio

(Friedman, McQ

Mesenteric Ischemic Colitis

• Intramural vessel hypoperfusion of segmental colon mucosa w/

regions affected, commonly splenic flexure & rectosigmoid jun• Presents w/sudden onset LLQ crampy abdominal pain, diarrhea

hematochezia. Dx w/thumbprinting on X-ray, colonoscopy w/shemorrhage, ulceration, & necrosis.

• Tx self-limiting, transfusion & antibiotics, or resection. Tx unde

etiology of hypotension.(Friedman, McQ



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Lower GI Tract Blood LoDiverticular Bleed• Colon mucosal, submucosal, & muscle layer herniations, i.e

ranging few millimeters to centimeters long, result from incintraluminal pressure, common on left-side of colon, asymp

• Presents as painless hematochezia. Self-limiting, but if sevwith colonoscopy or mesenteric angiography or tagged RBC

(Friedman, M

Postpolypectomy Bleed• Bleeding, hematochezia, persisting hours to days after colonosc polypectomy, particularly large polyps greater than 2 cm in sizedue to usage of NSAIDs, ASA, or anticoagulant medications too

polypectomy performed.

• Most self-limiting. Dx & tx if necessary with colonoscopy.(Friedman, M



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Lower GI Tract Blood LoRadiation Colitis

• Mucosal injury & ulceration up to 6-18 months after radiati

• Presents with rectal pain and recurrent hematochezia. Dx wcolonoscopy or barium studies. Often self-limiting, but if txsupplementation & w/colonoscopy & either bipolar coagula

probe, laser, or commonly argon plasma coagulation (APC)(Friedman, McQ

Meckel’s Diverticulum• GI tract congenital anomaly w/ileal diverticulum containing

mucosa, 1-10cm long, occurring w/in 100cm of ileocecal vain children with painless melena or hematochezia.

• Dx with Meckel’s (technetium) scan. Tx resection. (Friedman, McQ

LGI Tract Blood Loss: Case


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LGI Tract Blood Loss: Case•What is the DDx?

Ischemic colitis or infectious colitis.

•What do you do?

X-ray reflects thumbprinting. GI consulted forcolonoscopy reflective of ischemic colitis, no

necrosis. Broad spectrum antibiotics &conservative treatment measures provided.

Figure 22. Ischemic Co

Gastrointestinal Site. (2014). Is

http://www.gastro



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Lower GI Tract Blood LoColon Etiologies:

•Infectious Colitis

• Mesenteric Ischemic Colitis

• Diverticular Bleed

• Post Polypectomy Bleed

• Radiation Colitis

• Meckel’s Diverticulum• Colon Cancer (see Occult Blood loss)

• Arteriovenous Malformations (AVMs)

• Crohn’s Disease (see IBD lecture)

• Ulcerative Colitis (see IBD lecture)



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Rectal Etiologies:

• Rectal Fissure

• Hemorrhoidal Bleed

• Crohn’s Disease

(see IBD lecture)• Rectal Varices

(see portal HTN) Figure 23. Rectum. From OrgansoftheBorectum, rectum function with parts

http://www.organsofthebody.c

L GI T t Bl d L


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Hemorrhoidal Bleed• Dilated internal & inferior venous plexus above & below t

line produced by chronic pelvic floor straining.

• Presents with hematochezia due to bleeding vessel or ulcer

• Tx for internal hemorrhoids is with dietary & stool softenimeasures &/or rubber band ligation, but 3rd & 4th degree in

hemorrhoids hemorrhoidectomy. Tx for external hemorrhodietary & stool softening measures, but if severe pain thenthrombectomy & hemorrhoidectomy.



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Rectal Fissure• Anal canal mucosal tear, crack, or ulceration usually along

midline, produced from passage of large &/or hard stool. Phematochezia with BM and pain during & after defecation

• Dx identified upon anal examination. Tx with dietary & st

softening measures, topical anesthetics (lidocaine, benzocatopical nitroglycerin compound), & sitz baths.

L GI T t Bl d L


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Rectal Etiologies:

•Rectal Fissure

•Hemorrhoidal Bleed

•Crohn’s Disease (see IBD lecture)

•Rectal Varices (see portal HTN)

Occult GI Tract Blood Lo


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Occult GI Tract Blood Lo•Colon Cancer

•

Diverticula (small & large intestine)• Vascular Ectasias

• Extraesophageal varices (gastric, small bowel, co

• Small bowel neoplastic lesions

•

Hemosuccus pancreaticus• Hemobilia

• Aortoenteric fistula

• Dieulafoy’s lesions

• Meckel’s diverticulum

Occult GI Tract Blood Lo


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Occult GI Tract Blood LoColon Cancer• Cancer growth, 85% initiated via adenomatous polyps, of the inner li

wall (I), involving the muscle layer (II), spreading to at least one lym

w/metastatic spread (IV). The 5yr survival of 39% of early stage pts stage pts w/mets is 19%. (Greenberger, Blumberg, & Burakoff, 2011; Hause

• Risk factors include FHx colorectal ca, age > 50yo, pt hx colorectal c polyps, ovarian/endometrial ca


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Occult GI Blood Loss: Case

•What is it?

Colon Cancer

•What do you do?

Dx with colonoscopy & biopsy,

resection, await pathology, image for

more information. Tx according toOncology recommendations. Encourage

family screening per Canadian Cancer

Society screening guidelines.(Canadian Cancer Society, 2015).

Figure 24. Colon Cancer Stages. From M

Understanding cancer of the colo

http://www.medicinenet.com/colorectal_cance

htm


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Resources

While practicing gastroenterology and hepatologyconsider the following published references:

• Current’s Diagnosis & Treatment GastroenterologyHepatology, & Endoscopy, Second Edition

•

Sleisenger & Fordtran’s Gastrointestinal & Liver DPathophysiology, Diagnosis, Management

• Mayo Clinic Gastroenterology & Hepatology Board

Figure 26. Bookstack. Huffingtonpost.com (n.d.).

to creationism: Watchdog report. Retrieved from

http://www.huffingtonpost.com/2013/10/18/texas-

creationism_n_4124692.html

Figure 25. Library Books. MoneyCrashers.com. (n.d.). 8 ways to save money on

college textbooks. Retrieved from http://www.moneycrashers.com/save-money-

college-textbooks/

R


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Resources

While practicing gastroenterology and hepatologconsider using the following professional organi

• Canadian Association for the Study of the Liver

• Canadian Association of Gastroenterology (CA• Canadian Liver Foundation (CLF)

Figure 5. Logo. From Canadian Association of Gastroenterology. (n.d.). Retrieved from https://www.cag-acg.org/; Figure 6. Logo. Fro


R


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Resources

•CASL has extensive online information & guidelines for livemanagement.

• CAG provides the CDDW annual conference, with the CAG/Postgraduate Course very appropriate for PAs practicing in Gin Canada combines the presentation of GI & liver research.

• CLF is a good site w/global GI conferences including CASL,AASLD & EASL (2 of 3 global liver annual mtgs presentingdisease research).

Figure 5. Logo. From Canadian Association of Gastroenterology. (n.d.). Retrieved from https://www.cag-acg.org/; Figure 6. Logo. Fro


R


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Resources

While practicing gastroenterology and hepatologconsider using the following professional journa publications:

• The Canadian Journal of Gastroenterology and

Hepatology, the journal of the CASL and CAG• Annuals of Hepatology

• Liver International

Figure 5. Logo. From Canadian Association of Gastroenterology. (n.d.). Retrieved from https://www.cag-acg.org/; Figure 6. Logo. Fr


R


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Resources

While practicing gastroenterology and hepatologconsider using the following professional organi

• American Association for the Study of Liver D

(AASLD)• American College of Gastroenterology (ACG)

• American Gastroenterology Association (AGA


(n.d.). Retrieved from http://www.gastro.org/; Figure 10. Logo. From American Association for the Study of Liver Diseases. Retrieved

R


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Resources

•

AASLD provides a Postgraduate Course, a Hepatology AssoCourse, & a General Hepatology Update for GI & hepatolog

NPs, & a NP/PA Clinical Hepatology Fellowship program. (N

Post-Graduate Program yet.)

• ACG provides a Postgraduate Course for PAs practicing in G

AGA provides a Principles of GI for NPs & PAs mtg. DDW conference present GI & hepatology research similar to the C

• AASLD, ACG, & AGA all have extensive online info & guid

GI & liver dz mgt promoting EVM.


(n.d.). Retrieved from http://www.gastro.org/; Figure 10. Logo. From American Association for the Study of Liver Diseases. Retrieved

Resources


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Resources

While practicing gastroenterology and hepatoloconsider using the following professional journ publications:

• Hepatology, the journal of the AASLD

•

The American Journal of Gastroenterology, theof the ACG

• Gastroenterology and the Clinical GastroenteroHepatology, journals of the AGA


(n.d.). Retrieved from http://www.gastro.org/; Figure 10. Logo. From American Association for the Study of Liver Diseases. Retrieve

Conclusion


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ConclusionAfter attending this lecture the attendee should be a

• Distinguish between upper, lower, and occult GI tract blood loss with estimation of their prevalence.

• Identify evaluative methods for diagnosis and treatmelower, and occult GI tract blood loss etiologies.

• Interpret clinical scenarios demonstrating upper, loweoccult GI tract blood loss presentation.

• Locate and share professional resources for GI & live

References


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American Academy of Physician Assistants. (n.d.). Logo. Retrihttps://aapa.org/

American Cancer Society. (2015). Cancer facts and statistics. R

from http://www.cancer.org/research/cancerfactsstatistics/

American College of Gastroenterology. (2015). Colorectal canc screening. Retrieved from http://patients.gi.org/topics/colorectascreening/

American College of Gastroenterology. (n.d.). Logo. Retrievedhttp://gi.org/

American Association for the Study of Liver Diseases. Logo. Rfrom http://www.aasld.org/

American Gastroenterology Association. (n.d.). Logo. Retrievehttp://www.gastro.org/

References


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AndyHanselman.com. (n.d.). 10 ‘dramatically different’ questiocreate dialogue with your customers. Retrieved fromhttp://www.andyhanselman.com/2013/02/27/10-dramatically-d

questions-to-help-create-dialogue-with-your-customers/Bighipslittlehips.com (2013). Everyone poops. Retrieved fromhttp://bighipslittlehips.com/2014/05/01/what-does-your-poop-syour-health-yesthis-is-a-post-about-poop/

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GI Track Blood Loss Questio


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Q

Figure 27. GI Tract. From Berne and Levy Ph

(2008). General anatomy of the GI system and

functional segments. Elsevier, Inc. New

Figure 26. Questions. From AndyHanselman.com. (n.d.). 10 ‘dramatically different’

questions to help create dialogue with your customers. Retrieved from

http://www.andyhanselman.com/2013/02/27/10-dramatically-different-questions-to-

help-create-dialogue-with-your-customers/

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Gastroenterology Approach to GI Track Blood Loss

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